Side Effects

You’ve made it through prostate cancer treatment successfully, and your doctor
has pronounced you cancer-free. You are probably feeling an overwhelming sense of
relief! The last thing you ever want to think about is that the cancer may come
back. It is up to you now to make sure it doesn’t by visiting your doctor
regularly and committing to a healthy lifestyle.

Awareness of your personal health has probably never been this high – you
have had to endure uncomfortable tests, even more uncomfortable treatments, and
maybe even some undesirable side effects. Because you have successfully navigated
through all of these experiences, you can now help other men and their families
to understand the disease, how it is treated, and what they can expect physically
and emotionally, as well as provide them with a source of support and inspiration.
Becoming an advocate for prostate cancer patients and their families can not only
help other men and their families, but can improve your own emotional recovery from
the disease.

This section gives a brief summary of what you need to do for the long-term to keep
the chance of cancer recurrence low. It also describes ways in which you can become
an advocate for prostate cancer awareness.

A prostate cancer diagnosis can be devastating for the patient and his spouse or
companion. The often-resulting erectile dysfunction and/or incontinence due to surgery
or other treatment can bring additional grief, confusion and trauma to couples during
an already stressful time. After treatment, many couples feel utterly unprepared
to deal with the physical and emotional impact on their intimate relationship. One
spouse confessed, “I though ED was the guy down the street, not a medical
condition that could devastate my marriage.”

Couples facing prostate cancer often feel the need to be more connected than ever.
Instead, confusion, embarrassment and fear caused by ED can cause both parties to
feel alone and disconnected.

In the midst of this difficult news, it is important to know that there is HOPE.
Perhaps more importantly, there are options that make mutually satisfactory
sexual relationships possible in the presence of ED and impotence. In this instance,
information truly is power. Paired with open and frank discussion and a willingness
to explore options, couples facing ED can find satisfying solutions.

Prostate Cancer & ED

So what exactly is ED and why is it so closely linked with prostate cancer?

Normal male sexual function is a constellation of processes, including desire, emotional
and psychological considerations, and physical function. Erectile dysfunction --
commonly known as impotence -- is defined as the inability to achieve or maintain
an erection that is sufficient for satisfactory sexual intercourse. However, almost
all men who have ED/impotence can overcome it.

The reason ED can occur in men undergoing radical prostatectomy is due to damage
to the pelvic nerves that control erections. These nerves lie within millimeters
of the prostate. During surgery, the nerves may be cut or stretched. This may cause
temporary or permanent impotence, although sexual desire and the ability to achieve
orgasm should remain. The causes of impotence following radiation and cryosurgery
are less clear but may be a combination of fibrosis, damage to blood vessels or
damage to the tissues inside the penis. Hormone therapy can also cause a reduction
in libido and possible difficulties with erections. This is generally reversible
when the therapy is discontinued.

The Journey To Solutions

Many couples who have successfully faced ED and prostate cancer stress the many
facets of their journey:

Acknowledging the grief of the loss of their intimate life as they knew it before

Recognizing the fear that the level of intimacy they previously enjoyed would not
return

Making a choice to remain open and discuss their feelings and concerns

Remaining willing to examine their intimate life and possibly redefine intimacy

Staying committed to exploring options and finding solutions.

Erectile dysfunction and sexual intimacy can be challenging to discuss under the
best of circumstances. Add the stress of a prostate cancer diagnosis, and the challenge
to remain open can be multiplied. When sexual challenges arise, many couples suffer
far too long because the lines of communication shut down and fear takes over. Those
who are successful at finding solutions are those who are willing to keep the lines
of communication open, even when it is uncomfortable or difficult.

Most couples do not realize is that there are many possible solutions to restoring
sexual intimacy, even after prostate cancer treatment. From pills, to external devises,
injections and surgical procedures, there are solutions for nearly everyone. With
persistence, a little humor, open discussion, and medical support, couples can reclaim
sexual intimacy once again.

Fortunately there are many medical professionals, generally urologists, who specialize
in treating ED. An excellent urologist is one who is:

Sensitive to the difficult nature of the topic

Able to engage in open and frank discussion with the patient and his spouse or companion

Exceptionally knowledgeable and skilled in a large variety of treatment options
for restoring sexual function

Diane, whose husband, was diagnosed with prostate cancer in 1999, says this about
their journey, “After treatment we were just so glad that he was alive. As
the months passed, we resumed our lives, except an important part was now mysteriously
gone. After one failed attempt in the bedroom, we both shut down and pretended to
focus on other things. I didn’t want to pressure him and he was too embarrassed
to discuss it. One year later, we were both deeply sad and disconnected. On a weekend
vacation, we both started crying and acknowledged our fears. After a tearful discussion,
we recommitted to our intimacy and began our quest for solutions with a wonderful
urologist. It was not always smooth sailing, some options didn’t work for
us and others worked only for a while. Persistence won the day though. Five years
later, we have a wonderful relationship again and far better communication than
ever before.”

Don’t let ED become a silent, unwelcome, over-bearing house guest. If you
and your spouse are facing ED, whether is it the result of prostate cancer treatment
or not, do not let fear, embarrassment, or discomfort destroy your love life. Become
knowledgeable about ED. Seek help from medical professionals who specialize in sexual
function and keep the lines of communication open.

Erectile Dysfunction - information from The National Kidney and Urologic
Diseases Information Clearinghouse (NKUDIC), part of the National Institutes of
Health of the U.S. Department of Health and Human Services

Prostate cancer is now the most common internal malignancy in men. The lifetime
prevalence of prostate cancer is 1 in 6 men. With the more widespread use of the
Prostate Specific Antigen (PSA) blood test for prostate cancer screening, 60% of
all prostate cancers are discovered while still localized. Many urologists recommend
radical prostatectomy (removal of the prostate gland and lymph nodes) as the treatment
of choice for their patients who are younger and in good health and have localized
cancer. One of the major side effects of this surgery is urine leakage (incontinence).

Although urine leakage is temporary for many men after removal of the prostate gland
for prostate cancer, persistent leakage is not uncommon. Patient surveys have shown
a 39-63% prevalence 1 year after surgery, with 24-56% of patients wearing incontinence
pads. The incidence depends in part on the expertise of the surgeon; more experienced
surgeons have much lower rates. This persistent leakage can have significant medical,
psychological, social, and economic consequences. Many men have said that incontinence
was the most burdensome part of their experience with prostate cancer treatment.

Treatments

There are non-surgical treatments available that have proven effective for many
men with leakage after prostate surgery:

Pelvic Muscle Exercises – done properly, these strengthen the muscles
that help prevent urine loss. They are most helpful in men with small amounts of
leakage. How to perform Pelvic Muscle exercises (also
known as Kegel exercises)

Bladder Control Techniques – training to use muscles to help prevent
leakage during coughing, sneezing or physical activity. Training can also be done
to learn to reduce urgency, so men can make it to the bathroom in time.

Biofeedback – training techniques in which muscle and bladder activity
can be monitored and displayed on a screen so that men can learn to accurately control
their pelvic muscles and reduce leakage.

Electrical Stimulation – home or office treatments in which low electrical
current is used to help strengthen the pelvic muscles and make the bladder less
irritable.

Medications – taken every day, these help reduce urgency and urge-related
leakage, but are not helpful for leakage with coughing, sneezing, or physical activity.

Practical Tips

When planning to go home after surgery, bring a pair of Jockey-type underwear (not
boxers) and incontinence pads. After the catheter is removed post surgery, patients
may be unable to prevent urine from leaking. This is normal, and may occur for a
variable period of time. Most men improve significantly by 1-2 months although it
can take up to one year.

After surgery, stress incontinence is quite common. Urinary leakage occurs when
getting out of a car, standing up from a chair, or coughing or sneezing. Again,
this is normal.

Stay away from caffeine.

Emptying your bladder before it is completely full can minimize the leakage.

Talk with your doctor about your level of leakage, and to learn more about the non-surgical
treatment options listed above.

Urinary Incontinence in Men - information from The National Kidney and Urologic
Diseases Information Clearinghouse (NKUDIC), part of the National Institutes of
Health of the U.S. Department of Health and Human Services

As prostate cancer advances, your bones can be impacted. Bone health may be affected
by prostate cancer and its treatment.

Treatment-induced bone loss – often occurs with androgen deprivation therapy
due to the reduced level of testosterone; it occurs following bilateral orchiectomy
or when an LHRH agonist or antagonist is administered. (The list includes Lupron®
or Eligard (leuprolide acetate), Zoladex® (goserelin acetate
implant), Trelstar (triptorelin pamoate), Vantas LR (histrelin acetate)

Bone metastases – A result of advancing prostate cancer, when the disease
spreads to the bones

Radiation therapy to the bone and some kinds of chemotherapy also might decrease
bone density and increase the risk for bone loss

Bone Metastases and Advancing Prostate Cancer

Another situation in which bone is affected by prostate cancer is when the cancer
metastasizes, or breaks away and travels—usually via the bloodstream—to
other parts of the body, primarily in the advanced stages of the disease. When this
happens in prostate cancer, the most common place for the cancer to go is to the
bone. The bones most commonly affected are the spine, hips, and ribs. Normal bone
is constantly being remodeled, or broken down and rebuilt. Cancer cells that have
spread to the bone disrupt the balance between the activity of osteoclasts (cells
that break down bone) and osteoblasts (cells that build bone), disrupting their
normal remodeling and causing excessive bone breakdown or abnormal build-up. Bone
metastases cause damage that may make the bone more susceptible to complications
such as pain and fractures.

Prostate cancer behaves differently in each individual. In many men, prostate cancer
never spreads to any other site. In the men in whom it does spread, bone metastases
occur in 65% to 75% of all patients, and the bone is often the only site of metastases.

Prostate cancer that spreads to the bones is still prostate cancer, not bone cancer.
Bone metastases result in areas of weak, unstable bone that could cause debilitating
pain and fractures.

Spinal or Vertebral Compression Fractures

Although the majority of spinal fractures (also called vertebral compression fractures
or VCFs) are caused by osteoporosis, cancer and medical treatments such as hormone
therapy and chemotherapy can also weaken bone and increase the likelihood of fracture.

About 1 million American men are now receiving androgen deprivation therapy (ADT),
also known as hormone therapy, annually -- 19% are at an elevated risk of developing
vertebral compression fractures (VCFs). Men on androgen deprivation therapy should
have their bone density measured and treatment should be administered when it is
low. FDA approved medications are available.

Treating Pain Associated With Advanced Prostate Cancer

When prostate cancer has spread to other tissues in the body, particularly the bones,
it can cause pain. Radium-223 (Xofigo) has recently been approved, which treats
this pain and prolongs survival. External beam radiation or systemic radiation therapy
such as samarian-153 (Quadramet®) and strontium-89 (Metastron®)
can reduce bone pain caused by metastases. Bisphosphonate medications, usually pamidronate
(Aredia®) and zoledronic acid (Zometa®), can reduce
skeletal related events that include pain, fracture and the need for radiation or
surgery.

Xgeva™ (denosumab) is indicated for the prevention of skeletal-related events
in patients with bone metastases from solid tumors. Xgeva is a fully human monoclonal
antibody that binds to RANK Ligand, a protein essential for the formation, function
and survival of osteoclasts (the cells that break down bone). Xgeva prevents RANK
Ligand from activating its receptor, RANK on the surface of osteoclasts, thereby
decreasing bone destruction.

Prostate Cancer and Bone Health: The Bottom Line

An independent, successful, satisfying life is possible with prostate cancer. Because
prostate cancer has an affinity for your bones, knowing about your bones is important.
You can make a difference in managing your bone health:

Don’t let symptoms scare you. See them as a signal to get more information
and take action.

Not all symptoms represent recurrence of prostate cancer.

Maintaining your bone health will help maintain your quality of life.

If you have symptoms that concern you, quickly tell your health care provider.

The sooner your symptoms are diagnosed, the more that can be done to help.

Long-Term Care Issues

If you’ve been treated for prostate cancer and have been declared cancer-free
by your doctor, chances are you’re biggest worry is that the cancer may come
back. Sticking to your follow-up appointment schedule and living healthy can keep
your risk of recurrence low.

Your doctor will schedule routine follow-up examinations, usually every 6 months
for 5 years, and then yearly. He will test your serum PSA level at regular intervals,
usually every 3 to 6 months for 1 to 2 years and then annually. Your doctor may
also perform yearly DRE's. A repeat prostate biopsy may be performed in men
on active surveillance or those treated with radiation therapy, cryosurgery, or
HIFU if the PSA increases.

It’s important for you to realize that PSA levels normally fluctuate, and
that if your PSA levels begin to rise a few years after radiation treatment, it
may not mean that the cancer has returned. Make sure that you commit to taking a
PSA test as recommended by your doctor and talk candidly with your doctor about
any concerns you may have.

Increase intake of soy products that contain isoflavones, which may reduce
testosterone, although its effect in men with prostate cancer is not well
studied

Many foods contain antioxidants, substances that can prevent cell damage and may
enhance the immune system and reduce the risk of cancer and infection. A low-fat
diet of fish, fruits, vegetables, and grains contain antioxidants and may decrease
the risk of cancer.

Regular exercise has been shown to strengthen the immune system and improve digestion,
circulation, and the removal of waste products from the body. In men with prostate
cancer, exercise can help reduce osteoporosis and the weight gain associated with
androgen deprivation therapy. Exercise also prevents obesity, which is a risk factor
for many diseases, including cancer. Regular exercise may also reduce the risk of
benign prostatic hyperplasia (BPH), or prostate gland enlargement.

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